British Thoracic Society Guideline for pleural disease

Outcomes of Vacuum-Assisted Closure in Patients with Empyema Thoracis: A 10-Year Experience

BACKGROUND

Video-assisted thoracic surgery is currently the recommended treatment for patients with empyema thoracis. However, open-window thoracostomy (OWT) is not uncommon and is performed as a last resort in patients who are in poor general condition or with complicated empyema. Although several professional associations have recommended vacuum-assisted closure (VAC) as an adjunct to standard treatment, exact data regarding the clinical role of intrathoracic VAC are not available. The primary objective of this study was to determine the safety and efficacy of intrathoracic VAC in debilitated patients and to compare the results with those of previous OWT studies.

METHODS

We investigated 127 patients with a poor performance status who initially received inpatient intrathoracic VAC for stage II/III empyema thoracis between January 2010 and December 2020.

RESULTS

The median duration of VAC was 15 days, and the median length of stay was 18 days. Two patients had complications, and the in-hospital mortality rate was 11.8% (15 of 127). Among the 112 surviving patients, 25 (22.3%) were discharged with OWT and 87 (77.7%) were discharged with a closed chest. Empyema recurred in 5 patients. Ultimately, we recorded an absolute success rate of 64.6% (82 of 127).

CONCLUSIONS

Intrathoracic VAC appears to be safer and associated with less morbidity and mortality than OWT in debilitated patients with empyema. Our results revealed a reduced hospital length of stay and an improved success rate. The results of this work should contribute to improving treatment success in pleural empyema patients.

A Practical Approach to Pneumothorax Management

Pneumothorax, defined by the presence of air in the pleural cavity, is a potentially life-threatening condition requiring prompt diagnosis and tailored management. Rapid and accurate diagnosis is primarily achieved through radiological imaging. Management strategies for pneumothorax vary according to severity and aetiology. Conservative care, involving vigilant observation and supplemental oxygen, is suitable for small, stable pneumothoraxes. Needle aspiration can be an effective first-line treatment, although it may fail in some instances, necessitating escalation. Ambulatory devices facilitate outpatient care and reduce the length of hospital stays. Chest drainage remains a cornerstone therapy. Indwelling pleural catheters may be implemented in selective cases. Endobronchial treatments, including valves and spigots, offer minimally invasive options for reducing the flow of air leaks. Medical thoracoscopy with talc poudrage provides both diagnostic and therapeutic benefits in patients unsuitable for surgery, while surgical intervention represents the gold standard for definitive treatment. Adjunctive interventions include talc slurry pleurodesis and autologous blood patch pleurodesis for patients unsuitable for surgery. Effective management necessitates individualized treatment plans, incorporating risk factor modification, pain management, and physiotherapy. This practical approach aims to update the reader on the treatment modalities that can be used in all forms of pneumothorax in clinical practice.

Chest tube drainage versus repeated therapeutic thoracentesis for the management of pleural infections: a retrospective multicentre propensity-matched study

BACKGROUND

Drainage of infected pleural fluid is pivotal in the management of pleural infections, either by chest tube drainage (CTD) or repeated therapeutic thoracocentesis (RTT), in association with the use of intrapleural fibrinolytic therapy (IPFT) and DNase.

METHODS

The aim of this study was to compare the efficacy and the safety of these two methods of pleural drainage. We conducted a multicenter retrospective study, which included all the patients who was hospitalized for suspected pleural infection in three university hospitals between 2012 and 2021 drained by CTD or RTT. A propensity-score matching was performed to compare patients drained by RTT (RTT group) and by chest tube (CTD group) with adjunctive IPFT and DNase.

RESULTS

Two hundred and twenty-nine patients with suspected pleural infection were included. After a propensity-score matching, 78 patients were included in the final analysis, divided in two groups of 39 patients each. Patients in RTT group had a reduced length of drainage (6 days [4.3-8] vs 9 [6.5-13], OR = 1.41, 95%CI [1.05-1.89]) and a reduced length of hospital stay (15 days [11.5-21.5] vs 21 [14-30.5], OR = 1.28, 95%CI [1.01-1.61]). There was no significant difference in mortality rates, surgical referral, relapse, and drainage-related complications between the two groups.

CONCLUSIONS

The management of pleural infections through RTT with IPFT and DNase appears to be as effective and as safe as CTD. Randomized controlled trials comparing RTT and CTD would be required to confirm these results.

Chest drainage or repeated thoracentesis for pleural infections: a clinical dilemma

Pleural infection is a key clinical challenge, especially in immunocompromised patients and in those with pulmonary comorbidities. Its incidence has increased owing to antibiotic resistance and aging of the population. While international guidelines recommend chest tube (CTD) placement for complicated parapneumonic effusions (CPPE), the optimal strategy for fluid drainage is debated. Repeated therapeutic thoracentesis (RTT) could be an alternative to help patient mobility and reduce infectious risk. Studies on RTT demonstrated efficacy similar to that of CTD, mainly when combined with intrapleural fibrinolytic therapy and DNase, whereas others showed higher treatment escalation rates. In the issue of the Journal, Charron et al. show that RTT, combined with IPFT and DNase, decreases both pleural drainage duration and hospital stay when compared with chest drainage, without increasing mortality, surgical referral, or complication rates. However, methodological concerns, including variability in pleural infection definition, retrospective design, and centre-dependent treatment strategies, might limit the generalizability. Large-scale randomized controlled trials are needed to definitively establish its role.

Malignant Pleural Effusion: Palliative Managements and Indication for Pleurodesis Based on Survival Scores

Neoplastic pleural effusion is one in which malignant neoplastic cells are detected in the pleural fluid or in the parietal pleura. When secondary, it confirms disseminated neoplastic disease and suggests a reduced life expectancy and low quality of life. This review was described by a group of physician members of the Brazilian Society of Oncological Surgery regarding the treatment of neoplastic pleural effusion, developed to guide surgeons, palliative care physicians and clinical oncologists in their clinical practice to assess patients indicated for pleurodesis based on survival scores.

Safety and Efficacy of Pressurized Intra-Thoracic Aerosol Chemotherapy in Non-Small Cell Lung Cancer Pleural Carcinomatosis: Preliminary Results of a Pilot Study

Pleural carcinomatosis (PC) and malignant pleural effusion (MPE) affect up to 20% of patients with non-small cell lung cancer (NSCLC) and are usually synonymous with poor prognosis. Pressurized Intra-Thoracic Aerosol Chemotherapy (PITAC) is a novel and promising technique to control MPE in PC-NSCLC. This pilot study aimed to assess the feasibility, safety, and efficacy of PITAC in terms of palliative pleurodesis and evaluate the local antineoplastic control by analyzing patient-derived primary cell cultures. From January to December 2023, seven patients underwent PITAC with tailored doses of cisplatin and doxorubicin. There were four males and three females, with a median age of 65 (IQR:19) years. No operating room contamination by aerosolized chemotherapeutics was observed. No intraoperative complications occurred, and 30-day mortality was nil. One patient developed a postoperative prolonged air leak. The median chest tube stay was 2 (IQR:2) days, and the median hospital stay was 4 (IQR:2) days. No systemic toxicity nor hypersensitivity to chemotherapeutics were observed. All patients developed effective pleurodesis in 30 days. Cell cultures obtained from biopsy of PC-NSCLC sampled before PITAC formed confluent and monolayer sheets of attached tumor cells, while after 30 min from PITAC, cultures exhibited a significant reduction in the cancer cells' growth. Effective pleurodesis was observed three and six months after surgery in all patients. PITAC is a safe and effective technique to control MPE recurrence and might revolutionize loco-regional therapy for PC-NSCLC. Further research should assess its oncological role.

The role of artificial intelligence in the diagnosis, imaging, and treatment of thoracic empyema

PURPOSE OF REVIEW

The management of thoracic empyema is often complicated by diagnostic delays, recurrence, treatment failures and infections with antibiotic resistant bacteria. The emergence of artificial intelligence (AI) in healthcare, particularly in clinical decision support, imaging, and diagnostic microbiology raises great expectations in addressing these challenges.

RECENT FINDINGS

Machine learning (ML) and AI models have been applied to CT scans and chest X-rays to identify and classify pleural effusions and empyema with greater accuracy. AI-based analyses can identify complex imaging features that are often missed by the human eye, improving diagnostic precision. AI-driven decision-support algorithms could reduce time to diagnosis, improve antibiotic stewardship, and enhance more precise and less invasive surgical therapy, significantly improving clinical outcomes and reducing inpatient hospital stays.

SUMMARY

ML and AI can analyse large datasets and recognize complex patterns and thus have the potential to enhance diagnostic accuracy, preop planning for thoracic surgery, and optimize surgical treatment strategies, antibiotic therapy, antibiotic stewardship, monitoring complications, and long-term patient management outcomes.

Oncolytic viruses: a promising therapy for malignant pleural effusion and solid tumors

Oncolytic viruses (OVs) are natural or recombinant viruses that can directly lyse tumor cells without damaging normal cells. They enhance anti-tumor immunity by releasing antigens and activating inflammatory responses within the tumor microenvironment (TME). This offers a new therapeutic approach for MPE and solid tumors. This review discusses the progress of OVs administered via intrapleural and intratumoral routes, emphasizing their potential in MPE treatment and the challenges posed by the complex intrapleural environment, which affects the direct interaction between OVs, tumor cells, and immune cells. This review also discusses the regulatory barriers, safety concerns and accessibility of oncolytic virus therapy.

Autologous Blood Pleurodesis Through an Indwelling Pleural Catheter for the Management of Prolonged Air Leak in a Malignant Hydropneumothorax

The British Thoracic Society guidelines recommend a surgical opinion in cases of prolonged air leak or failure of lung re-expansion after 3-5 days. The management of prolonged air leak in non-surgical candidates often proves to be more challenging, with no expert consensus guidelines on treatment options. There is a paucity of data for the treatment of patients with a prolonged air leak in the setting of a hydropneumothorax, who are not suitable surgical candidates. We present the case of a novel treatment approach for an 89-year-old male with a symptomatic, large malignant pleural effusion treated initially with a routine chest tube drainage. Subsequent management was complicated by a hydropneumothorax with a persistent and large volume air leak. He was treated successfully with an autologous blood pleurodesis using an indwelling pleural catheter. Here we describe a novel management approach for persistent air-leak in the setting of a malignant hydropneumothorax. Autologous blood pleurodesis via an indwelling pleural catheter appears to be a safe and effective treatment option for non-surgical candidates and allows ongoing long-term drainage of a malignant effusion and air leak.

Advanced imaging techniques and artificial intelligence in pleural diseases: a narrative review

BACKGROUND

Pleural diseases represent a significant healthcare burden, affecting over 350 000 patients annually in the US alone and requiring accurate diagnostic approaches for optimal management. Traditional imaging techniques have limitations in differentiating various pleural disorders and invasive procedures are usually required for definitive diagnosis.

METHODS

We conducted a nonsystematic, narrative literature review aimed at describing the latest advances in imaging techniques and artificial intelligence (AI) applications in pleural diseases.

RESULTS

Novel ultrasound-based techniques, such as elastography and contrast-enhanced ultrasound, are described for their promising diagnostic accuracy in differentiating malignant from benign pleural lesions. Quantitative imaging techniques utilising pixel-density measurements to noninvasively distinguish exudative from transudative effusions are highlighted. AI algorithms, which have shown remarkable performance in pleural abnormality detection, malignant effusion characterisation and automated pleural fluid volume quantification, are also described. Finally, the role of deep-learning models in early complication detection and automated analysis of follow-up imaging studies is examined.

CONCLUSIONS

Advanced imaging techniques and AI applications show promise in the management and follow-up of pleural diseases, improving diagnostic accuracy and reducing the need for invasive procedures. However, larger prospective studies are needed for validation. The integration of AI-driven imaging analysis with molecular and genomic data offers potential for personalised therapeutic strategies, although challenges in data privacy, algorithm transparency and clinical validation persist. This comprehensive approach may revolutionise pleural disease management, enhancing patient outcomes through more accurate, noninvasive diagnostic strategies.

Thoracic Ultrasound for Pre-Procedural Dynamic Assessment of Non-Expandable Lung: A Non-Invasive, Real-Time and Multifaceted Diagnostic Tool

Non-expandable lung (NEL) occurs when the lung fails to fully re-expand after pleural fluid drainage, complicating management and limiting therapeutic options. Diagnosis, based on clinical symptoms, pleural manometry, and traditional imaging, is often delayed to the peri- or post-procedural stages, leading to improper management, complications, and higher healthcare costs. Therefore, early, pre-procedural diagnostic methods are needed. Thoracic ultrasound (TUS) has emerged as a non-invasive tool with the potential to enhance diagnostic accuracy and guide clinical decisions, yet, it remains inadequately studied within the context of NEL. We conducted a non-systematic narrative review using a structured methodology, including a comprehensive database search, predefined inclusion criteria, and QUADAS-2 quality assessment. This approach ensured a rigorous synthesis of evidence on TUS in NEL, with the aim of identifying knowledge gaps and guiding future studies. Non-invasive, real-time, bedside M-mode TUS has demonstrated efficacy in predicting NEL prior to thoracentesis by detecting an absent sinusoidal sign and reduced atelectatic lung movement. Emerging experimental techniques, including 2D shear wave elastography (SWE), speckle tracking imaging (STI) strain analysis, the lung/liver echogenicity (LLE) ratio, TUS assessment of dynamic air bronchograms, and pleural thickening evaluation, show additional potential to enhance pre-procedural NEL detection. However, all these methods have significant limitations that require further comprehensive investigation. Despite their significant promise, TUS modalities for early NEL detection still require rigorous validation and standardization before broad clinical use. A multimodal diagnostic approach, combining clinical manifestations, pleural manometry, radiologic and ultrasonographic findings, along with emerging techniques (once fully validated), may provide the most extensive framework for NEL. Regardless of advancements, patient-centered care and shared decision-making remain essential. Further research is needed to improve outcomes, reduce healthcare costs, and enhance long-term treatment strategies.

Comparative study between ultrasound-guided closed pleural biopsy and thoracoscopic pleural biopsy in undiagnosed exudative pleural effusions

Pleural biopsies are often required to establish a diagnosis in exudative pleural effusions, which remain undiagnosed after initial pleural fluid analysis. Medical thoracoscopy offers a high diagnostic yield but has limited availability in resource-constrained settings. This prospective comparative study evaluated the diagnostic yield between ultrasound-guided closed pleural biopsy and medical thoracoscopy among patients with undiagnosed exudative pleural effusions with pleural-based lesions at least 10 mm in size. Both groups achieved an equal diagnostic yield of 92% despite fewer biopsy specimens being taken in the ultrasound-guided biopsy group (4.52±0.65) compared to the thoracoscopic group (7.8±1) (p<0.0001). In conclusion, ultrasound-guided closed pleural biopsy is a suitable alternative to medical thoracoscopy in patients with undiagnosed exudative pleural effusion having pleural thickening or nodularity of at least 10 mm in size in terms of having similar diagnostic yield as compared to medical thoracoscopy.

Pleural Effusion: Shedding Light on Pleural Disease Beyond Infection and Malignancy

Background and Objectives: Non-malignant pleural effusions (NMPEs) are the most frequently encountered pleural disease. They arise from various non-malignant, non-infectious clinical conditions, including cardiac, renal, and hepatic organ dysfunction. Despite their wide prevalence, there is a lack of literature for NMPE. This publication aims to provide an updated overview of the causes, diagnostic strategies, and management options for NMPE. Materials and Methods: This review synthesizes findings from studies published on NMPE, focusing on the presentation, diagnosis (such as imaging and pleural fluid analysis), and management strategies. Studies were selected based on relevance and were analyzed to provide a comprehensive summary of current practices. Results: The review highlights different etiologies of NMPE, including organ-specific factors. Imaging, pleural fluid analysis, and clinical correlation remain crucial in diagnosing the etiology of NMPE. Treatment strategies are largely dependent on the underlying condition. Medical management remains the mainstay for many causes. In some cases, interventions, such as thoracentesis, tunneled indwelling pleural catheter, or pleurodesis, are necessary. Conclusions: NMPE is a heterogeneous condition with a wide prevalence and significant implications. They present a diagnostic and management challenge due to patient complexity and evolving therapeutic options.

Tension pneumothorax from large bowel herniation and perforation as a late presentation of traumatic diaphragmatic hernia during pregnancy: a case report

BACKGROUND

Diaphragmatic hernias can be congenital or acquired, with trauma being the primary cause of the latter. Both types may have delayed presentations, with abdominal organs protruding into the thoracic cavity, causing symptoms of varying severity. Pregnancy can sometimes precipitate the condition. Tension pneumothorax resulting from bowel perforation into the thorax is exceptionally rare, with only a few cases reported. To the best of the authors knowledge, this is the third documented case of a late-presenting trauma-related diaphragmatic hernia during pregnancy, complicated by tension pneumothorax.

CASE PRESENTATION

A 30-year-old woman, 29 weeks pregnant, was referred to Semmelweis University emergency department with moderate dyspnea. Initial investigation revealed tension pneumothorax. Chest tube placement released air, pus, and feces. Computer tomography identified a diaphragmatic hernia with bowel incarceration and perforation as the underlying cause. The patient underwent a delayed cesarean section and surgical repair, with a good outcome. A history of thoracic trauma eight years prior was later revealed.

CONCLUSION

Evaluating pregnant patients with shortness of breath in the emergency department is challenging. Identifying a history of thoracic or abdominal trauma is crucial, as this can raise the suspicion of diaphragmatic hernia, which can present with a wide range of symptoms. Spontaneous tension pneumothorax in pregnant women is extremely rare and requires cautious management. A multidisciplinary approach is crucial for the successful treatment of maternal diaphragmatic hernia.

Pleural Infection: Diagnosis, Management, and Future Directions

Pleural infection represents a significant and ongoing challenge for patients, clinicians, and healthcare providers given the morbidity and mortality associated with this condition. Whilst our understanding of how pleural infection develops and how it should be treated has improved considerably over the past couple of decades, this has yet to translate into a meaningful positive impact on key outcomes. Making the diagnosis of pleural infection is not always straightforward, and the long-standing belief that it always occurs as a complication of lung parenchymal infection is being increasingly recognised as incorrect. Identifying the causative organism(s) is equally uncertain, with almost half of cases of pleural infection proving to be culture negative using traditional methods. Whilst we are now able to determine which patients are more likely to have a poor outcome from their pleural infection at the time of diagnosis, how this should affect their treatment pathway-including the role of more invasive strategies such as surgery or intrapleural enzyme therapy-is not yet known. This review article aims to summarise the existing evidence base and best clinical practice for the non-specialist, whilst highlighting recent research which has or will change the way we manage pleural infection, as well as those areas where further studies are still needed.

Training, experience and perceptions of point-of-care ultrasound among internal medicine trainees: Implications for training, curriculum development and service delivery

Point-of-care ultrasound (POCUS) has revolutionised modern-day medicine and has widespread utilisation throughout healthcare settings. Despite the availability of ultrasounds, there are no requirements for internal medicine trainees (IMTs) to undergo any form of POCUS training. This study aimed to explore the perceptions and experience of IMTs of POCUS. A multicentre survey was distributed via mass email to all internal medicine trainees (IMT1-ST8) across two deaneries in south-west England. A total of 42% (213/509) IMTs completed the survey. Of these, 97% (207/213) contributed to the acute medical or general medical rota and 95% (202/213) of trainees reported performing invasive procedures on call. Training in ultrasound site selection was reported by 30% (63/213) of IMTs, and 11% (23/213) worked in a trust with accessible POCUS training. Formal POCUS accreditation was reported by 16% (34/213) of trainees. Identifying sonographic findings of common medical conditions was considered useful by 86.9% of trainees. Identifying pleural effusions being the most useful (99%, 211/213), while identifying a deep vein thrombosis was the least (87%,185/213). Higher confidence scores were reported for ultrasound-assisted as opposed to ultrasound-guided ascitic or pleural procedures, although this was not significant. On a 10-point Likert scale, most trainees highly rated POCUS training (median = 10, interquartile range 8-10). Free text responses supported POCUS training in the IMT curriculum. We found that IMTs perceive POCUS training as highly valuable. However, few IMTs are obtaining sufficient experience or training of POCUS. Opportunities for enhanced POCUS training should be embedded in training programmes.

Tumor markers determination in malignant pleural effusion: pearls and pitfalls

Serum and pleural fluid tumor markers are well-recognized auxiliary diagnostic tools for malignant pleural effusion (MPE). Here, we discuss some pearls and pitfalls regarding the role of tumor markers in MPE management. The following issues are discussed in this article: What is the appropriate clinical scenario for evaluating pleural tumor markers? Which tumor markers should be advocated for diagnosing MPE? Can extremely high levels of tumor markers be employed to establish a diagnosis of MPE? Does the serum-to-pleural fluid ratio of a tumor marker have the same diagnostic efficacy as the measurement of that marker alone in the pleural fluid? Can tumor markers be used to estimate the risk of specific cancers? What should be considered when interpreting the diagnostic accuracy of tumor markers? How should tumor marker studies be performed? We addressed these issues with published works, particularly systematic reviews and meta-analyses.

Prognostic significance of pleural fluid microbiological positivity in pleural infection: a bicentric 10-year retrospective observational study

BACKGROUND

Despite its heterogeneity, there is currently limited data in pleural infection phenotyping. Using pleural fluid characteristics, pleural infection can be classified into microbiological-positive pleural infection (MPPI) and microbiological-negative pleural infection (MNPI). This study aimed to evaluate the prognostic significance of microbiological positivity in pleural infection, and to evaluate the performance of RAPID (renal, age, purulence, infection source, dietary factor) score in these subgroups.

METHODS

Consecutive patients hospitalized for pleural infection over a 10-year period in two acute-care hospitals in Hong Kong were evaluated. According to the pleural fluid characteristics, they were classified into MPPI and MNPI, respectively. Survival was evaluated using multivariate Cox regression analysis. Performance of RAPID score to predict mortality at 3-month and 1-year was evaluated using C-statistics.

RESULTS

In total, 381 patients with pleural infection were included. They were classified into MPPI (n = 169) and MNPI (n = 212), respectively. The MPPI group had more elderly home residence and use of large-bore chest tube, and higher Charlson comorbidity index and RAPID score, compared to the MNPI group. Length-of-stay, the need of surgery and intensive care were similar between the two groups. MPPI was associated with significantly increased risk of mortality (adjusted hazard ratio [aHR] 1.46, 95% CI 1.08-1.98). Three-month mortality was significantly higher in MPPI compared to MNPI (24.9% vs. 10.4%, p < 0.001; adjusted odd ratio 2.05, 95% CI 1.11-3.80). The trend continued at 1, 3, 5 and 7 years. RAPID score predicted 3-month and 1-year mortality in both groups (C-statistics, MPPI 0.71, 0.75; MNPI 0.84, 0.81). In the MPPI group, presence of Staphylococcus aureus (aHR 2.26, 95% CI 1.43-3.57) and Gram-negative organisms other than Enterobacteriaceae (aHR 2.00, 95% CI 1.10-3.61) were associated with worse survival, while presence of Streptococcus anginosus group was associated better survival (aHR 0.50, 95% CI 0.32-0.78), when compared to their absence.

CONCLUSIONS

Pleural fluid microbiological positivity is independently associated with increased mortality in patients with pleural infections. This finding should complement the RAPID score in risk stratification and inform future research aimed at improving outcomes in this patient population.

Quality Improvement Initiatives for Pleural Infection Managed with Intrapleural Therapy

Rationale: Pleural infection is associated with significant mortality, and its management is complex. Little attention has been given to care-process metrics such as management delays, pleural drainage practices, and adequacy of intrapleural therapy administration despite their potential impact on outcomes. Audits revealed gaps in those care processes in our institution. Objectives: To assess the impact of quality-improvement initiatives on pleural effusion management in adults. Methods: We performed a retrospective comparison of patients treated with intrapleural therapy for pleural infection at the McGill University Health Center before (April 2013 to April 2016; N = 109) and after interventions (June 2020 to June 2021; N = 44). Interventions included a pleural drainage policy and order set, an intrapleural therapy protocol and preprinted order, implementation of intrapleural therapy administration by nurses, local pleural infection guideline development, and an online learning module for physicians. Major outcomes (length of stay, mortality, surgical treatment) and care-process metrics (management delays, pleural drainage practices, intrapleural therapy administration) were compared between the two periods. Results: After implementation of the interventions, in-hospital mortality and length of stay were unchanged, but the incidence of surgical management went from 14% to 0% (P = 0.01). Delays in drain insertion and intrapleural therapy initiation were not significantly different. Insertion of drains smaller than 12 F decreased from 51% to 7% (P < 0.001). Drain blockage decreased from 20% to 2% (P = 0.004). The incidence of additional drain insertion went from 62% to 48% (P = 0.12). After interventions, 70% of intrapleural therapy doses were given by nurses, the intrapleural therapy protocol was more often adequately followed, fewer doses were missed, and less extended therapy was prescribed. Complications related to drain insertion and intrapleural therapy were similar between the two periods. Conclusions: After the implementation of multifaceted quality improvement interventions for pleural infection including the involvement of nurses in pleural drain flushing and intrapleural therapy, improvements were observed in intrapleural therapy administration, chest drainage practices, and need for surgery. However, length of stay, mortality, and management delays were unchanged.

Complications during chest tube drainage for iatrogenic pneumothorax

Background

Iatrogenic pneumothorax is a common complication of diagnostic and therapeutic pulmonary procedures. New guidelines on primary spontaneous pneumothorax suggest ambulatory approaches may be suitable. However, guidance on iatrogenic pneumothorax occurring in patients with impaired lung function, increased age, comorbidity and frailty is lacking, and the safety profile of ambulatory management is not known. The objective was to study the safety of iatrogenic pneumothorax treated with chest tubes and to identify the risks of life-threatening events.

Methods

In a retrospective cohort of patients admitted and treated with an adhesive valve-integrated chest tube system, we recorded the incidence of complications. The primary outcome was the incidence of life-threatening events that required urgent medical action. Incidences of serious adverse events, adverse events, serious device-related events and whether outpatient ambulatory treatment would be safe were recorded based on the review of the medical charts.

Results

In 97 patients, 6 (6%) life-threatening events occurred, including episodes of respiratory failure and an urgent need for new chest tube insertion. The event incidence was 21% in patients with pre-biopsy saturation below 95% and 1% in patients with saturation above 95%, p = 0.003, and greater if the lung had not expanded on the first radiograph, 25%, after insertion of the chest tube, than if the lung had fully expanded, 4%, or partially expanded, 2%, p = 0.009.

Conclusions

The incidence of life-threatening events during chest tube-treated iatrogenic pneumothorax is significant, but acceptable in patients without impaired lung function prior to the procedure and early response to treatment.

Tumor Markers in Pleural Fluid: A Comprehensive Study on Diagnostic Accuracy

Background/Objectives: Malignant pleural effusions (MPEs) pose a significant challenge in clinical practice and exert a considerable socio-economic burden on the healthcare system, affecting approximately 1 million individuals annually. These effusions are a leading cause of debilitating dyspnea and a diminished quality of life among cancer patients, with distant metastasis to the pleural layers occurring in about 20% of cases during treatment. Methods: A cross-sectional, observational case-control study was conducted on 151 Bulgarian patients with a hydrothorax. The control group included 72 patients with benign diseases, confirmed via biopsy, with 38 having inflammatory and 34 non-inflammatory pleural effusions. The other 79 patients had malignant pleural involvement. These groups are representative of the main types of pleural pathology. Results: The study found that all of the tumor markers, except for PIVKA-II (Protein induced by vitamin K absence-II), showed statistically significant differences between the malignant and non-malignant patient groups, with CAE (carcinoembryonic antigen) and CA19-9 showing the most notable differences. The Receiver Operating Characteristic (ROC) analysis revealed that CA72-4 had the best ability to distinguish between the two groups, while PIVKA was the weakest, with optimal cut-off values for all of the relevant tumor markers being derived using the Youden index. Conclusions: In conclusion, our study highlights the transformative potential of pleural fluid tumor markers as precise and minimally invasive resources for distinguishing malignant from non-malignant pleural effusions. These findings pave the way for improved diagnostic accuracy and personalized clinical management, addressing a critical gap in the care of patients with pleural pathologies.

Tunneled Pleural Catheters: An Effective Nonsurgical Alternative for Nonexpandable Lung in Chronic Pleural Infection

BACKGROUND

Open window thoracostomy (OTW) is the standard of care for debilitated patients with chronic pleural infection and nonexpandable lungs (NEL) who are not candidates for major surgical intervention. Tunneled pleural catheters (TPC) offer tremendous treatment potential in this setting based on their efficacy in malignant pleural effusion and NEL. We aim to assess the efficacy, safety, and health care utilization of TPC in this setting.

METHODS

We retrospectively evaluated patients who underwent TPC procedures for the long-term management of chronic pleural infection and NEL who were not candidates for major surgical intervention. Clinically, complete treatment success was defined as fever abatement, normalization of white cell count, and stoppage of antimicrobial therapy without requiring surgical intervention. It is deemed a partial success if chronic antimicrobial suppression is still needed.

RESULTS

There were 20 patients who had TPC placed for chronic pleural infection with NEL. Clinical and partial treatment success was achieved in 9/17 and 8/17 patients, respectively, excluding 3 patients who were placed on comfort measures only. The median change in pleural volume was -218 mL. The median length of stay after TPC placement was 4.5 days. TPC was removed in 8 patients due to successful obliteration of pleural space in a median duration of 46.5 days. Four patients passed away with TPCs in place, 7 retained TPCs at the last health care system contact, and 1 patient had OTW due to TPC failure.

CONCLUSION

This exploratory study suggests that TPC is an effective and safe intervention for the management of patients with chronic pleural infection and NEL lung who are not candidates for surgical intervention.

The evolving role of medical thoracoscopy on therapeutic management of pleural disease

PURPOSE OF REVIEW

The use of medical thoracoscopy (MT) has gained widespread acceptance for the diagnosis and management of pleural disease. It is less invasive compared to video-assisted thoracoscopic surgery (VATS), can be performed in the endoscopy suite and in patients who are unfit to undergo general anaesthesia. It is safe, with high diagnostic yield, and enables pulmonologists to intervene therapeutically.

RECENT FINDINGS

There have been several developments in this field, particularly for malignant pleural effusions (MPE). Specifically, we discuss further techniques that can be employed during MT to distinguish between benign and malignant pleural disease. There is also potential for combined thoracoscopic talc poudrage (TTP) and indwelling pleural catheter (IPC) insertion to shorten hospital stay.

SUMMARY

Beyond MPE, we discuss the role of MT in patients with pneumothorax and pleural infection. We discuss the advantages and disadvantages of MT over traditional practices in a variety of conditions - diagnosis of exudative pleural effusions, prevention of recurrent MPE and pneumothoraces as well as treatment of pleural infections, so as to better aid physicians in selecting the optimum procedure for patients.

American Association of Bronchology and Interventional Pulmonology Essential Knowledge in Interventional Pulmonology Series: Selected Topics in Malignant Pleural Disease

The goal of the American Association of Bronchology and Interventional Pulmonology Essential Knowledge in Interventional Pulmonology Series is to provide clinicians with concise, up-to-date reviews of important topics in the field of interventional pulmonology. This 3-year alternating rotation of primary topics will start with a focus on selected topics in malignant pleural disease. In this article, we update the reader on malignant pleural effusion in 3 parts: part 1-diagnosis, focusing on imaging and fluid biomarkers; part 2-management, with review of multimodal approaches, cost considerations, and evolving targeted therapies; and part 3-pleural mesothelioma. These reviews complement the Essential Knowledge in Interventional Pulmonology Lecture Series presented at the 2023 AABIP Annual Conference, available for viewing on the AABIP website (https://aabip.memberclicks.net/essential-knowledge-in-interventional-pulmonology-series).

Six Versus Three Doses of Intrapleural Streptokinase in Childhood Empyema: A Randomized Controlled Trial

OBJECTIVE

To compare the efficacy and safety of administering six doses of intrapleural streptokinase (SK) versus the conventional three doses, in children with empyema.

STUDY DESIGN

In this open label, placebo-controlled, randomized trial, we enrolled 53 children with empyema, who received three doses of intrapleural SK. Thereafter, those without clinical improvement (n = 34) and those showing clinical improvement but having persistent pleural fluid width > 10 mm on chest ultrasonography (n = 13), were randomized to receive three additional doses of SK, or three doses of placebo (normal saline). The remaining 6 children improved clinically and radiologically, hence were not randomized. The outcomes recorded were cumulative volume of pleural fluid drained, total duration of intercostal drainage, time taken for clinical improvement, duration of hospitalization, proportion of children with treatment failure requiring surgery, and adverse events. Spirometry, 6-min walk test, chest X-ray and ultrasonography were done 3 months following discharge. We analyzed by intention-to-treat.

RESULTS

The baseline characteristics of children who received six versus three doses SK were comparable. There was no statistically significant difference in the cumulative volume of fluid drained; median (IQR): 810.0 (330.0, 1630.0) [95% CI: 505, 1463] mL versus 530.0 (255.2, 1325.0) [95% CI: 325, 1131] mL, p 0.46. There were no significant inter-group differences in the total duration of intercostal drainage, time taken for clinical improvement, duration of hospitalization, treatment failure, surgical decortication and adverse events.

CONCLUSION

In children with empyema, intrapleural therapy with six doses of SK is not superior to three doses, although it is safe.

What You Need to Know About: The Management of Malignant Pleural Effusion

Malignant pleural effusion (MPE) is a common complication of malignancy and is regularly seen on the general medicine take. Diagnosis of MPE is indicative of advanced or metastatic disease and carries a poor prognosis, with median survival ranging from 3 to 12 months. Despite recent advancements in systemic anti-cancer treatment, the goal of management in MPE remains the palliation of symptoms. This article reviews the current guidelines and evidence on the assessment and management of MPE. Assessment involves imaging techniques such chest X-ray and computed tomography (CT) scans, whilst thoracic ultrasound has a crucial role in guiding diagnostic procedures. Diagnostic pleural aspiration remains a cornerstone for establishing a tissue diagnosis, although its yield is variable depending on tumour type. Emergence of targeted immunotherapy has necessitated the need for large tissue samples for molecular testing, driving the need for pleural biopsies in relevant cases. Management encompasses therapeutic aspiration, chemical pleurodesis and indwelling pleural catheter insertion, each offering distinct benefits and considerations. Recent developments in equipment and combined approaches have enhanced patient outcomes and quality of life. The complexity of MPE requires a patient-centred approach to assessment and management and where possible patients should be managed with specialists in pleural disease on an outpatient basis.

Lemierre syndrome: case presentation of a life-threatening septic pneumonia with complicated parapneumonic effusion: A case report

RATIONALE

Lemierre syndrome is a rare, life-threatening complication of oropharyngeal infections.

PATIENT CONCERNS

A 35-year-old man started with an upper respiratory infection but worsened the clinical course with sepsis and acute respiratory failure with complicated bilateral pleural effusion.

DIAGNOSES

The patient was diagnosed with typical Lemierre syndrome with lung complications.

INTERVENTIONS

Antibiotic therapy with bilateral pleural percutaneous drain with fibrinolysis.

OUTCOMES

The patient improved and was discharged without oxygen therapy after antibiotics were covered and active lung care with complicated parapneumonic effusion. After discharge, lung function showed restrictive lung defect but improved compared to the initial exam.

LESSONS

Lemierre syndrome, which might begin as a mild upper respiratory infection, can progress to a critically ill disease accompanied by sepsis and metastatic septic embolus. The patient suffered septic lung emboli with bilateral complicated parapneumonic effusion but was successfully treated with percutaneous drainage with pleural fibrinolysis, appropriate antibiotics, and anticoagulants. Early suspicion of the disease and active treatment are necessary to treat rare syndromes like Lemierre syndrome.

Efficacy of povidone-iodine as an effective pleurodesing agent: an experience from a teaching hospital

The management of persistent malignant pleural effusion (MPE) or uremic pleural effusions requires the removal of pleural fluid and the prevention of recurrence through pleurodesis. Pleurodesis involves injecting a sclerosing agent into the pleura to encourage adhesion between the two layers, ultimately obliterating the pleural space. Povidone-iodine is a potential pleurodesing agent. This quasi-experimental study was conducted at the Department of Pulmonology, Shaikh Zayed Hospital, Federal Postgraduate Medical Institute, Lahore, Pakistan, over one year (March 2021- March 2022). A total of 70 patients with MPE, uremic pleural effusions, and secondary spontaneous pneumothorax (SSP) were enrolled after meeting the inclusion criteria. The pleurodesis procedure involved administering a mixture of 20 mL of 10% povidone-iodine solution and 30 mL of normal saline through a chest tube, followed by clamping for 3 hours. Patients were scheduled for follow-up visits at 2, 4, 8, and 12 weeks. Data was analyzed using SPSS version 20.0. The average age of participants was 53.26 years (+13.71). Of the 70 patients, 39 (55.7%) were male and 31 (44.3%) were female. 62 patients (88.57%) had pleural effusion, and 8 patients (11.42%) had pneumothorax. The procedure was successful in 84.3% of patients, with varying success rates by diagnosis: MPE (81%), uremic pleural effusion (92%), and SSP (75%). Statistical analysis revealed significant positive effects of povidone-iodine on procedure outcomes (p=0.048) and effectiveness in preventing pleural effusion recurrence (p=0.028). This study indicates that 10% povidone-iodine can serve as a viable alternative to other pleurodesis agents, yielding standard-quality pleurodesis in 84.3% of patients. It is readily available, cost-effective, and has minimal adverse effects.

Intrapleural fibrinolytic therapy for pleural infections: Outcomes from a cohort study

Introduction

Pleural infections are a significant cause of mortality. Intrapleural fibrinolytic therapy (IPFT) utilising alteplase and dornase is a treatment option for patients unsuitable for surgery. The optimal dose of alteplase is unknown, and factors affecting treatment success in an Asian population are unclear. We sought to determine the factors affecting treatment success in Tan Tock Seng Hospital, Singapore and evaluate the efficacy of lower doses of IPFT.

Method

A retrospective analysis of patients with pleural infections treated with IPFT between July 2016 and November 2023 was performed. Treatment success was defined as survival without surgery at 3 months. Data, including patient demographics; comorbidities; RAPID (renal, age, purulence, infection source and dietary factor) scores; and radiological characteristics, were extracted from medical records and analysed. Linear mixed effects model and logistic regression were performed to determine factors affecting treatment success.

Results

A total of 131 cases were analysed. Of these, 51 (38.9%) reported positive pleural fluid culture, and the most common organism was Streptoccocus anginosus. Mean age was 65 years (standard deviation [SD] 15.5). Mean time from chest tube insertion to first dose of IPFT was 10.2 days (SD 11.5). Median starting dose of alteplase was 5 mg. Treatment success was reported in 112 cases (85.5%). There were no significant differences between the alteplase dose and radiological clearance. Patient age (odds ratio [OR] 0.94, confidence interval [CI] 0.89-0.98) and interval between chest tube insertion to first dose (OR 0.95, CI 0.91-0.99) were statistically significant variables for the treatment success.

Conclusion

Lower starting doses of alteplase remain effective in the treatment of pleural infection. Early IPFT may result in better outcomes.

CT features associated with contralateral recurrence of spontaneous pneumothorax

INTRODUCTION

Spontaneous pneumothorax recurs in 30-54% of patients without surgery. Identifying individuals likely to suffer a recurrence, who might benefit from pre-emptive surgery, is challenging. Previous meta-analysis suggested a relationship between contralateral recurrence and specific CT findings.

METHODS

We analysed CT images and recurrence rates of 243 patients seen by our tertiary referral pneumothorax service.

RESULTS

We validated the meta-analysis observation that contralateral lung cysts are associated with a higher risk of contralateral recurrence in younger individuals. Furthermore, we observed that the size of contralateral cysts to be associated with increased contralateral recurrence in younger patients.

CONCLUSION

The detection of contralateral lung cysts might therefore help identify younger patients more likely to benefit from pre-emptive surgery.

Beyond diagnosis: maximizing the role of medical thoracoscopy in pleural disease treatment

Medical thoracoscopy has been extensively utilized in the diagnosis of pleural disease, yet its potential therapeutic applications remain underutilized. This article presents a comprehensive overview of the various uses of medical thoracoscopy in managing pleural diseases. It has been employed to facilitate thoracic drainage and reduce hospitalization duration of patients with complicated parapneumonic effusions and empyema. Additionally, medical thoracoscopic occlusion therapy can be used for bronchoscopic closure and refractory pneumothorax. However, there is currently a lack of standardized protocols for utilizing medical thoracoscopy to reduce the volume of giant emphysematous bullae. Furthermore, medical thoracoscopy allows for pleurodesis or photodynamic therapy in patients with malignant pleural effusion. Nevertheless, further high-quality clinical research is needed to validate these findings.

Endobronchial Valve Insertion for the Management of Persistent Air Leak Following Pneumothorax

Persistent air leak following a pneumothorax refers to air leakage lasting 5-7 days after the initial event. Different strategies have been used with varying degrees of success including surgical or chemical pleurodesis. Endobronchial valve (EBV) insertion is a technique where the insertion of a one-way valve obstructs the flow of air through the leak and helps in pneumothorax resolution especially if surgery is contraindicated. We present the case of a gentleman in his 60s who was admitted with a right-sided pneumothorax on the background of grade 4 glioblastoma. A 12-French chest drain was inserted for the management of his pneumothorax. A CT scan was requested due to failure of resolution of pneumothorax at five days post chest drain insertion, evidenced by ongoing bubbling in the underwater seal. CT revealed moderate right-sided pneumothorax and a possible bronchopleural fistula arising from the right upper lobe posterior segment bronchiole. He was unfit for surgery. A second chest drain was inserted but the air leak did not settle. It was then decided to insert EBV using bronchoscopy under sedation and Zephyr valves were used for this procedure. Balloon blockage of the right upper lobe led to the disappearance of air leak in the underwater seal on -5 kPa suction whereas blocking individual branches did not lead to the termination of air leak, therefore, it was decided to insert valves on all the segments of the right upper lobe. Four days after the EBV insertion his air leak resolved and his chest X-ray (CXR) showed a resolution of pneumothorax, so his chest drain was removed. He was subsequently discharged home. EBV insertion can facilitate pneumothorax resolution and discharge in carefully selected patients and should be used with a multi-disciplinary approach. In our case, this approach helped to facilitate the transfer of a terminally ill patient to his preferred place of comfort.

Outcomes and Trends of Open Thoracotomy and Video-Assisted Thoracic Surgery for Surgical Management of Catamenial Pneumothorax: A 10-Year Retrospective Cohort Study of a Thai Population

Background Catamenial pneumothorax (CP) is characterized by pneumothorax associated with menstrual cycles and thoracic endometriosis. This study aimed to review the outcomes and trends for surgical treatment of CP in King Chulalongkorn Memorial Hospital. Methodology We included females aged 18 to 50 years who underwent surgery for CP between January 2012 and December 2022. A total of 17 patients were identified. A retrospective data collection from each patient was done, including demographic data, surgery type (open vs. video-assisted thoracic surgery (VATS)), pleural procedures, length of stay, and complications. Results The mean age at surgery was 36.29 years (±6.78). The median follow-up period was 36 months (range = 12-122). Pneumothorax occurred predominantly on the right side (94.12%), and pelvic endometriosis was present in all patients. All 17 patients underwent surgery, with open surgery in six and VATS in 11 patients. Diaphragmatic procedures were performed in 15 patients, with pleurectomy in nine, lung resection in 11, and pleurodesis in 10 patients. Pleurectomy was significantly associated with a reduced recurrence rate (p = 0.029). Diaphragmatic lesions were absent in two cases, and four patients experienced recurrence. Conclusions This cohort study of CP in the Thai population demonstrated that pleurectomy is associated with lower recurrence. There was no difference in recurrence between open surgery and VATS. Corresponding to the British Thoracic Society Guideline 2023, pleurectomy may help reduce recurrence.

Iatrogenic Haemothorax: A Life-Threatening Complication Following A 12Fg Seldinger Intercostal Drain Insertion for Pneumothorax

A man in his 30s with no previous medical history presented to the emergency department with acute dyspnoea. His chest X-ray (CXR) showed a massive left-sided pneumothorax, and a 12Fg post-intercostal drain (ICD) was inserted. Twenty-four hours later there was evidence of blood in the drain, and he had a significant haemoglobin drop of 44 g/l in only one day. His vital signs were stable. A CXR and an urgent computed tomography (CT) scan showed a large haemothorax therefore he was transferred to the tertiary thoracic centre, where he was taken to theatre and had a thoracoscopy and evacuation of a blood clot. Follow-up two weeks later showed complete resolution of the haemopneumothorax. This case report highlights the rare complication of a massive iatrogenic haemothorax. This was despite all the safety precautions including normal coagulation and platelet count, the patient not being on any anti-coagulant drugs and an ICD approach via the triangle of safety for insertion of the small-bore tube. In the case of iatrogenic haemothorax, urgent resuscitation and surgical treatment are needed as this is a life-threatening situation.

LEARNING POINTS

Iatrogenic haemothorax post-intercostal drain (ICD) insertion has not been reported in recent literature since the new British Thoracic Society (BTS) guidelines advised ultrasound-assisted procedure for pleural effusions, and a 'triangle of safety' for pneumothorax patients. Nevertheless, it should be included in the differential diagnoses as it still could happen.If it is a massive haemothorax, cardiothoracic surgeons must be notified immediately.Point-of-care ultrasound can be used to diagnose pleural fluid while awaiting a chest X-ray. However, point-of-care ultrasound will not be able to differentiate between blood and normal pleural fluid, whereby a formal chest CT can.

Chest Tubes and Pleural Drainage: History and Current Status in Pleural Disease Management

Thoracostomy and chest tube placement are key procedures in treating pleural diseases involving the accumulation of fluids (e.g., malignant effusions, serous fluid, pus, or blood) or air (pneumothorax) in the pleural cavity. Initially described by Hippocrates and refined through the centuries, chest drainage achieved a historical milestone in the 19th century with the creation of closed drainage systems to prevent the entry of air into the pleural space and reduce infection risk. The introduction of plastic materials and the Heimlich valve further revolutionized chest tube design and function. Technological advancements led to the availability of various chest tube designs (straight, angled, and pig-tail) and drainage systems, including PVC and silicone tubes with radiopaque stripes for better radiological visualization. Modern chest drainage units can incorporate smart digital systems that monitor and graphically report pleural pressure and evacuated fluid/air, improving patient outcomes. Suction application via wall systems or portable digital devices enhances drainage efficacy, although careful regulation is needed to avoid complications such as re-expansion pulmonary edema or prolonged air leak. To prevent recurrent effusion, particularly due to malignancy, pleurodesis agents can be applied through the chest tube. In cases of non-expandable lung, maintaining a long-term chest drain may be the most appropriate approach and procedures such as the placement of an indwelling pleural catheter can significantly improve quality of life. Continued innovations and rigorous training ensure that chest tube insertion remains a cornerstone of effective pleural disease management. This review provides a comprehensive overview of the historical evolution and modern advancements in pleural drainage. By addressing both current technologies and procedural outcomes, it serves as a valuable resource for healthcare professionals aiming to optimize pleural disease management and patient care.

Prognostic significance of malignant pleural effusions in patients with advanced luminal B breast cancer

BACKGROUND

Though the survival of breast cancer (BC) patients with malignant pleural effusion (MPE) has been studied, this has not been specifically studied in the luminal B subtype. Therefore, this study investigated the characteristics and survival of luminal B-BC patients presenting with MPE.

METHODS

We retrospectively analyzed 141 patients diagnosed with postoperative advanced Luminal B breast cancer, including 54 cases with MPE and 87 cases without MPE at the Tianjin Cancer Hospital from January 2012 to January 2015. We assessed the clinical characteristics between the groups.

RESULTS

The mean age of all patients was 47 years, with no significant difference between the two groups. Altogether, 29 (33%), 24 (28%), 28 (32%), 45 (52%), and 10 (11%) patients had lung, liver, bone, lymph node, and chest wall metastases, respectively. In addition. The difference in overall survival between the two groups was not significant (P>0.05). However, cox regression analysis showed that only the tumor clinical stage at initial diagnosis was related to short overall survival. Further, we conducted a subgroup analysis and found that the higher the clinical stage at initial diagnosis in age < 50 years patients, the shorter the overall survival, while age > 50 years patients was not. (P < 0.05).

CONCLUSIONS

There was no difference in the overall survival between luminal B-BC patients with MPE and those without. Clinical stages at initial diagnosis were an independent prognostic factor for age < 50 years luminal B BC with MPE overall survival. Our results may help clinicians make positive decisions regarding personalized treatment of luminal B-BC with MPE.

The predictive value of the Haller index for recurrent pneumothorax risk after primary spontaneous pneumothorax

Background

In this study, we aimed to evaluate the predictive value of the Haller index for recurrence risk in primary spontaneous pneumothorax patients.

Methods

Between January 2018 and December 2023, a total of 285 patients (260 males, 25 females; median age: 23 years; range, 17 to 35 years) with primary spontaneous pneumothorax who underwent thoracic computed tomography and followed for at least one year were retrospectively analyzed. The patients were divided into two groups as the non-recurrence group (n=170) and recurrence (n=115) group. The Haller index was calculated from computed tomography scans at presentation and its predictive value for recurrent pneumothorax was estimated.

Results

The median age was significantly higher in the non-recurrence group than in the recurrence group (p <0.001). The median time to recurrence was two (IQR 1-3) months. The diagnostic validity of Haller index for predicting recurrence showed an area under the receiver operating characteristic of 0.824 (95% confidence interval [CI]: 0.775-0.866) (p <0.001). The optimal cut-off value of Haller index (>2.4) showed a sensitivity of 70.43% (95% CI: 61.2-78.6) and specificity of 76.47% (95% CI: 69.4-82.6).

Conclusion

A high Haller index is associated with increased recurrent pneumothorax risk in primary spontaneous pneumothorax patients. Traditionally used for pectus excavatum severity, incorporating Haller index in the management of these patients may help to identify high-risk patients and guide personalized management strategies.

Malignant Pleural Effusion: A Multidisciplinary Approach

Malignant pleural effusion (MPE) has become an increasingly prevalent complication in oncological patients, negatively impacting their quality of life and casting a shadow over their prognosis. Owing to the pathophysiological mechanisms involved and the heterogeneous nature of the underlying disease, this entity is both a diagnostic and therapeutic challenge. Advances in the understanding of MPE have led to a shift in the treatment paradigm towards a more personalized approach. This article provides a comprehensive review and update on the pathophysiology of MPE and describes the diagnostic tools and the latest advances in the treatment of this complex clinical entity.

Is chest tube omission safe for patients with primary spontaneous pneumothorax scheduled for video-assisted thoracoscopic surgery?

AIMS

Primary spontaneous pneumothorax (PSP) is a sudden pleural disease predominantly affecting healthy adolescents and young adults, making it a prevalent thoracic disorder within this demographic. This study evaluated the necessity of preoperative chest tube insertion for PSP patients and reassessed current clinical practices.

METHODS

We conducted a retrospective analysis of medical records for individuals aged 14-30 years diagnosed with PSP who underwent video-assisted thoracoscopic surgery (VATS) at Wonju Severance Christian Hospital from January 2016 to December 2022. Patients were categorized retrospectively into two groups based on their initial treatment: Those who had a chest tube inserted and those who did not. We collected and compared clinical data, including demographics, treatment specifics, and outcomes.

RESULTS

The study included 128 PSP cases. There was no difference in preoperative clinical data between the two groups, and there were no differences in operation time, number of wedge resections, and number of mechanical pleurodesis. However, the use of single-port surgery was significantly higher in the nonchest tube group (P = 0.001). The nonchest tube group had a significantly shorter hospital stay (P < 0.001), attributed to the absence of preoperative chest tube insertions. There were no significant differences in postoperative complications or recurrence rates between the groups.

CONCLUSIONS

In young PSP patients, proceeding directly to VATS without prior chest tube insertion in stable individuals does not lead to serious complications or negatively affect outcomes. This approach may offer an effective alternative for PSP management.

The Medical Management of Spontaneous Pneumothorax: A Concise Review

Spontaneous pneumothorax is an increasingly common clinical presentation, the management of which, until recent years, had remained unchanged for decades. A recent surge in pneumothorax research has produced the largest randomised controlled trials in the field yet and has revolutionised the management of spontaneous pneumothorax. The body of evidence supporting the introduction of conservative and ambulatory care in appropriate patients in recent guidelines now allows these patients, many of whom would otherwise have been admitted to hospital, to be managed in the outpatient setting and reduces their risk of complications compared to conventional chest drain insertion. In this review, we discuss recent advances in the management of pneumothorax and the evidence underpinning contemporary guidelines. We aim to equip physicians with the knowledge to engage their patients in the decision-making process regarding their pneumothorax, whilst keeping patient safety and patients' own preferences at the centre of their care.

Apolipoprotein E in patients with undiagnosed pleural effusion: a prospective diagnostic test accuracy study

INTRODUCTION

Pleural effusion is common in clinical practice, and its differential diagnosis remains challenging for clinicians. This study investigates the diagnostic value of apolipoprotein E (apoE) in patients with undetermined pleural effusion.

METHODS

This prospective, double-blind study enrolled 152 patients with undiagnosed pleural effusion. Their pleural fluid apoE levels were measured, and a receiver operating characteristics (ROC) curve was used to evaluate the diagnostic accuracy of apoE. Decision curve analysis (DCA) was used to assess apoE's net benefit. Subgroup analyses were performed to investigate the effect of age on the diagnostic accuracy of apoE.

RESULTS

Among the included participants, 23 had heart failure (HF). HF patients had the lowest apoE level among pleural effusion patients. The area under the curve (AUC) of apoE for HF was 0.79 (95% CI: 0.69-0.89). At the threshold of 40 mg/L, the sensitivity and specificity of apoE were 0.96 (95% CI: 0.87-1.00) and 0.33 (95% CI: 0.25-0.42), respectively. The decision curve for apoE was above reference lines. The AUC of apoE decreased in older patients.

CONCLUSION

Pleural fluid apoE has moderate diagnostic value for HF and has net benefits in patients with undiagnosed pleural effusion. The diagnostic accuracy of apoE decreases with age.

Elusive Unilateral Pleural Effusion: Keys to Clinching the Diagnosis

Unilateral pleural effusions may sometimes be difficult to diagnose. The cause may vary widely, including congestive heart failure, chronic liver and kidney disease, various drugs, and underlying undiagnosed disorders of the lung and pleura. With advancements in chest imaging, new biomarkers, and less invasive methods for obtaining tissue samples, it may be possible to identify the cause of the unilateral pleural effusions whose etiology is unclear. Even reviewing patient history, re-examining pleural fluid, classifying effusions based on Light's criteria, and ruling out pseudoexudates can help understand the cause. We aim to discuss a case of unilateral pleural effusion and, on its backdrop, discuss an approach to elusive unilateral pleural effusion.

The Role of Medical Thoracoscopy with Talc Poudrage in Spontaneous, Iatrogenic, and Traumatic Pneumothorax: A Prolonged Experience of a Tertiary Care Center

INTRODUCTION

Medical thoracoscopy is a minimally invasive and safe procedure mostly performed for unexplained exudative pleural effusions but may be considered for pneumothorax (PNX).

METHODS

This retrospective study included participants affected by PNX who underwent medical thoracoscopy with talc poudrage at a single academic hospital from 2008 to 2021. The primary endpoint was the observation of complete radiographical lung re-expansion and absence of air supply from the chest drain within 7 days of medical thoracoscopy. The secondary endpoint was achieving no recurrence of ipsilateral PNX at 24 months post-discharge.

RESULTS

A total of 95 patients affected by primary spontaneous PNX (PSP), secondary spontaneous PNX (SSP), iatrogenic, and traumatic PNX were enrolled. An additional procedure was required by 17.89% of patients, and only one patient with SSP required subsequent surgery. Recurrence of PNX occurred on the same side within 24 months after discharge in 9.47% of patients, with a median time to recurrence of 13.5 months. The PSP group was significantly more likely to achieve the primary endpoint. Pleural morphology was significantly associated with reaching the primary endpoint, while receiving a cumulative dose of talc greater than or equal to 4 g during hospitalization was associated with a lower risk of meeting it. Receiving a cumulative dose of talc greater than or equal to 4 g led in all cases to the achievement of the secondary endpoint. Patients with iatrogenic and traumatic PNX had an excellent prognosis in both the short- and long-term evaluation.

CONCLUSION

Medical thoracoscopy is an effective procedure for treating PNX in the acute setting in selected cases while preventing long-term relapses. Large prospective clinical studies are needed to support and better define the role of medical thoracoscopy in current clinical practice.

A potential prospect: The novel treatment of intrapleural saline irrigation with intrapleural tyloxapol in treating thoracic empyema

The treatment for empyema thoracis has been evolving over the years, including the usage of intrapleural fibrinolytic therapy (IPFT), for example, alteplase with intrapleural deoxyribonuclease (DNase) to enhance the drainage of pleural effusion. Here, we report two cases of thoracic empyema that were successfully treated with intrapleural saline irrigation and intrapleural tyloxapol apart from parenteral antibiotics as the pillar of the treatment. Both patients averted surgical procedure (decortication) and were discharged well. Upon follow-up, both cases showed clinical cure, biochemical recovery, and radiological improvement, indicating a good treatment outcome. This is the first reported cases on combination of saline irrigation with tyloxapol as alternative treatment for pleural infection.

Thoracic ultrasound in guiding management of respiratory disease

INTRODUCTION

The use of ultrasound in respiratory disease has evolved substantially over the past two decades. From a test done to confirm the safe site of pleural fluid drainage, thoracic ultrasound has become a point-of-care test that guides the management of patients on respiratory wards, in clinics and endoscopy.

AREAS COVERED

This review overviews the process of ultrasound examination in the chest. It then delves into specific disease areas (pleural disease, lung disease, diaphragm disease, and invasive procedures) to highlight how thoracic ultrasound is being used to refine management. The review concludes with discussion on the training curricula and assessment tools for competency in thoracic ultrasound. Being a scoping review, literature searches were conducted on PubMed using relevant search terms.

EXPERT OPINION

In addition to its current uses, there are many avenues where thoracic ultrasound will soon be beneficial. Recent studies show promising roles in areas such as patient-tailored guidance of pleurodesis and non-invasively predicting lung re-expansion after pleural fluid drainage. In addition, auxiliary tools such as contrast-enhanced ultrasound and elastography are proving useful in identifying the etiology and directing the successful sampling of pleural and lung lesions. Studies are also exploring the utility of sonographic biomarkers such as echogenicity and septations to predict outcomes in pleural disease.

Diagnostic yields and safety of thoracoscopic cryobiopsies in Japan: A single-center retrospective observational study

BACKGROUND

Thoracoscopy is useful for diagnosing unexplained pleural effusions. A sufficient specimen volume is often difficult to obtain using forceps biopsies (FBs) but can be obtained with pleural cryobiopsies (CBs). This study aimed to assess the utility and safety of CB during thoracoscopy in the Japanese population.

METHODS

Patients who underwent thoracoscopic CBs at the Japanese Red Cross Medical Center between January 2017 and August 2023 were included in the study. Data were retrospectively analyzed, including clinical data, thoracoscopic findings, specimen size, diagnostic yield, and complications. The number of collected specimens and the freezing time were left to the discretion of the attending physician.

RESULTS

Twenty-six patients underwent thoracoscopic CB. Specimens obtained by CB were larger than those obtained by FB. Primary lung cancer was the most common cause of pleural effusion, followed by malignant pleural mesothelioma. CB contributed to the diagnosis in 24 of 26 cases (92.3%) and FB contributed to the diagnosis in 11 of 18 cases (61.1%). Severe fibrosis could be diagnosed in all 3 cases by CB, but not by FB. The common complications of CB included bleeding at the biopsy site and atelectasis, but no severe complications occurred.

CONCLUSIONS

The utility and safety of thoracoscopic CB for diagnosing pleural effusions in Japan were verified. The diagnostic yield, specimen size, and safety profile of CB support the diagnostic utility of this method.

Rheumatoid pleurisy confirmed by biopsy of a chest wall nodule by thoracoscopy under local anaesthesia

Rheumatoid pleurisy is common in patients with rheumatoid arthritis, but distinguishing it from other diseases, such as heart failure and tuberculous pleurisy, is often difficult. A man in his 70s with stable rheumatoid arthritis presented with cardiac enlargement and bilateral pleural effusion on chest radiography. Pleural fluid studies showed lymphocytosis, adenosine deaminase level of 51.6 U/L and rheumatoid factor level of 2245.3 IU/mL, suggestive of rheumatoid pleurisy and tuberculous pleurisy. Thoracoscopy under local anaesthesia revealed erythema of the parietal pleura, small papillary projections and fibrin deposits. H&E-stained biopsy specimens showed inflammatory granulomas with strong lymphocytic infiltration and non-caseating granulomas. He was diagnosed with rheumatoid pleurisy. His symptoms improved with 30 mg of prednisolone. This study highlights that biopsy using thoracoscopy under local anaesthesia effectively diagnoses rheumatoid pleurisy, which may be challenging to diagnose.